Chapter 35 - Acquired Problems of the Newborn Flashcards
Birth Trauma
Physical injury sustained by a neonate during labor and birth (US 1.84 per 1000)
Ultrasonography allows antepartum diagnosis of macrosomia, hydrocephalus, and unusual presentations-plan for at birth
Elective cesarean delivery can be chosen for some pregnancies to prevent significant birth injury
Cephalhematoma from forceps or vacuum extraction or from pressure on skull against pelvis
Skull fracture
Risk Factors for Birth Trauma
Maternal age 35 primigravida Oligohydramnios - low amniotic fluid Macrosomia - big baby Multifetal gestation Abnormal or difficult presentation Obstetric birth techniques Prolonged or precipitate labor Congenital anomalies
Soft Tissue Injuries
Erythema and ecchymosis
Petechiae - pin point hemorrhages
Abrasions and lacerations
Edema-presenting or dependent parts
Subconjunctival (scleral) or retinal hemorrhage
Caput succedaneum
Cephalhematoma
Forceps-site of application-linear
Lacs-scalpel-CS or scissors episiotomy-may need butterfly strip
Conjuctival and retinal hemorrhages-caused from ICP during birth, resolve on their own
Bleeding put infant at higher risk for ?
jaundice
Mongolian spot
more common in asians, indians, and mexicans, will fade
Skeletal Injuries
Immature, flexible skull can withstand a great degree of molding before fracture results
If fractured in usually linear or depressed
Linear, most commonly seen in parietal-not significant, no tx
Depressed fracture-”ping-pong ball” indentation-CT scan r/o bone fragments, damage to brain,bleeds
May or may not need surgery
(Clavicle fractures - most common, skull fractures can also occur)
Clavicle Fracture
Bone most often fractured during birth
Usually break is in middle third of bone
Risk factors: vacuum extraction, shoulder dystocia, birth weight > 8 pounds
S/S of fracture: limited movement of arm, crepitus, absence of moro on one side
Tx: gentle handling
Peripheral nervous system injuries
Erb-Duchenne palsy
- Brachial plexus injury
Klumpke’s palsy
- Lower plexus injury
Facial paralysis (paralysis)Erb’s Palsy
Brachial Plexus injury
Most common type of paralysis associated with a difficult birth, shoulder dystocia, vaginal breech birth, forceps or vacuum, maternal diabetes, prolonged second stage of labor
Upper plexus is injured from stretching or pulling the head away from the shoulder during a difficult birth
Arm hangs limply
Palsy
Tx of Erb’s: Intermittent immobilization across upper abdomen (can pin to shirt), ROM
Klumpke palsey: Less common, lower arm paralysis, wrist and hand flaccid, Tx: padding in hand, position, gentle exercise
If edema or hemorrhage is cause, good prognosis, if laceration of nerves may need surgery, full recover 88-92%
Facial paralysis-caused by pressure on facial nerve during birth-protect eye, assist feed
Central nervous system injuries
Intercranial hemorrhage (ICH)
-Subdural hematoma
-Subarachnoid hemorrhage
Spinal cord injuries-vaginal breech-not usually seen anymore
**Venus bleedsIntracranial hemmorhage ICH
Causes (usually by breech births, in premies more likely bc bones on head are firm so C-section)
Subdural: collection of blood in subdural space, caused by stretching and tearing of veins
Subarachnoid: most common type of ICH, trauma or hypoxia, venous
Infants of Diabetic Mothers Pathophysiology
Hyperinsulinemia
Infants of Diabetic Mothers At Risk For:
Congenital anomalies
Macrosomia
Birth trauma and perinatal hypoxia
Respiratory distress syndrome (RDS)
Infants of Diabetic Mothers
Hypoglycemia Hypocalcemia and hypomagnesemia Cardiomyopathy Hyperbilirubinemia and polycythemia Nursing care All infants born to mom with diabetes are more at risk !
Diabetes
Risk same for of mothers with diabetes or gestational diabetes
Better outcomes for babies when glucose levels are maintained WNL
Mechanisms not totally understood for problems, preg poss unstable glucose and episodes of ketoacidosis cause congenital anomalies
Later preg mom can’t produce enough maternal hyperglycemia=excessive fetal growth
Maternal ketoacidosis 50% fetal mortality
Congenital anomalies 3 x higher than of nondiabetic mothers, however GD dx mid to late preg not with increased anomalies
Cardiac, renal, musculoskeletal, CNS most frequently occuring anomalies-CHD 3 x higher
Macrosomia
LGA babies: Round face, chubby body, flushed complexion, enlarged organs, increased body fat-esp around shoulders . Placenta and cord are larger. BUT insulin does not cross blood brain barrier so brain is not enlarged
Babies body has been producing large amounts of insulin so at risk for ? - hypoglycemia
Babies body has been producing large amounts of insulin so at risk for ?
hypoglycemia
Hypoglycemia
Blood glucose less than 40
Can take several days for baby to regulate insulin levels
S/S: may be asymptomatic (agitated crying, apnea, seizures)
Also at higher risk for hypocalcemia and hypomagnesemia
Neonatal Infections Sepsis
(presence of microorganisms or their toxins in blood or other tissues)
Septicemia or septic shock
Neonatal Infections Preventative Measures
Handwashing <–
Standard Precautions
Antibiotic instillation into the eyes (to prevent clamedia and gonarhea)
Neonatal Infections Curative Measures
Breastfeeding
Medication administration
Sepsis
One of the most significant causes of neonatal morbidity and mortality
Immature immune system
Can acquire in utero, during labor, birth, and while in hospital
During birth: contact with infected birth canal-conjunctiva, oral cavity
Postnatal infections: catheters, ET tubes, parents hands, healthcare workers
Umbilicus, circ site, lacs
Early onset sepsis-24-72 hours after birth progress faster than late-onset-3-50% mortality rate
Late onset 7-30 days of age
Septic shock
**Prenatal infection by organisms that can cross placenta:
herpes (HSV), cytomegalovirus (CMV), rubella
Sepsis sick infant
Sick infant is an emergency
S/S : temp > 100.4, poor feeding, irritability, lethargy, tachycardia, resp distress, poor perfusion, hypothermia (won’t wake up, blue)
Culture : blood, urine, CSF
Tx with IV abx until cx are negative
(amycillin, gentamycin)
(everything has to be negative for 12 hours before they can go home)
What can nurses do ?
#1 HANDWASHING Clean equipment Eye ointment Cleanliness Bathing Cord care Circ care Promote breast feeding
Breast is best !
Passive immunity
Colostrum contains IgA-protects gut
Bacteriostatic effect on E.coli
TORCH infections **
Toxoplasmosis
O for other:
Gonorrhea
Syphilis
Varicella-zoster
Hepatitis B virus (HBV)
Rubella
Cytomegalovirus
HerpesToxoplamosis
Protozoan toxoplasma gondii parasite
Found in CATS, dogs, pigs, sheep, cattle
Contaminated soil
Consumption of raw or undercooked meats or seafood (oysters, clams, mussels)
**Changing cat liter
Many women all ready positive, but don’t want first primary (first) infection during pregnancy
Gonorrhea
Many women with gonorrhea also have chlamydia
EES 0.5% ointment w/in 1 hour***
If infant actually develops gonococcal eye infection need dose of ceftriaxone
Systmeic gonorrhea_hosp IV abx
Syphilis
On the rise
If mom not tx during preg 50% of infants will have
Risk factors: lack of or late prenatal care, substance abuse,multiple partners,poverty,homelessness
Untreated mom stillbirth 30-40%
***Copper colored maculopapular rash palms, soles, around mouth and anus
Varicella-Zoster
Chickenpox and shingles-members of herpes family
90% of women of child bearing age are immune (bc either had it or had vaccine)
Can cross placenta-congenital anomalies if in first half of preg
Infants can have VZIG if exposed (varicella-zoster immune globulin
Hepatitis B(HBV)
35% will be preterm
Transmission rate from mom to fetus 70-90%
Transplacental transmission, serum
***Infants of positive mothers need hepatitis B immunoglobulin (HBIG) within 12 hours of birth, they also receive Hep B vaccine at same time
HIV
6000 women with HIV give birth in the US each year
1-2 % transmission with antiviral meds
May not test positive at first, need to be retested intermittently (through 1st year of life)
Do not breastfeed
Rubella
German measels
Congenital worse if mom contracts during first trimester
Hearing loss, cataracts, glaucoma, cardiac defects, IUGR, microphthalmia, (small eyes and ears)
(now have 2 MMR vaccines so why we don’t see rubella)
Cytomegalovirus (CMV)
**Most common cause of congenital viral infections
40,000 Nb’s in the US yearly
90% if infants are asymptomatic at birth
5-15% chance will develop hearing loss or learning disability later
“Blueberry muffin rash” papular, non-blanchable, purpuric
Herpes Simplex Virus (HSV)
Not uncommon Can be transplacental Congenital infection is rare Usually contracted in birth canal Can have herpetic skin lesions (vesicular) (Tx) Acyclovir (if fluid filled vesicle then think herpes 0 chicken pox is a form of herpes) (if get herpes in CSF then very bad)
Bacterial infections
Group B streptococci Escherichia coli Staphylococcus aureus Listeriosis Chlamydia infection
Group B Strep (GBS)
**Leading cause of neonatal morbidity and mortality in the US
Early onset up to 7 days-risk factors: low birth weight, preterm, ROM > 18 hours, maternal fever, intrauterine fetal monitoring, maternal age <20, Hispanic or African-American ethnicity
Late on set 1 week to 3 months-30% develop meningitis
Fungal Infections
Candidiasis—Candida albicans
Thrush (oral), plaques
Diaper dermatitis
Can be acquired from mom, yeast
Tx oral or topical nystatin
(baby can give to mom on nipples from breast feeding)
Substance Abuse
Tobacco
Alcohol
-Fetal alcohol syndrome (FAS)
-Alcohol-related neurodevelopmental disorders
-Alcohol-related birth defects
Heroin
Methadone
Marijuana
Cocaine
Methamphetamines
MDMA/Ectasy
Caffeine
Selective serotonin reuptake inhibitors (SSRIs)
(All lead to) Neonatal abstinence syndrome (NAS)
Methadone
Synthetic opiate
Drug of choice for heroin addiction since 1965
Crosses placenta
Methadone withdrawal resembles heroin withdrawal
Increased incidence of SIDS
Neurodevelopmental outcomes (increase risk of learning disabilities)
***** s/s of NAS
jitteriness, tremors, sucking, rub faces on bed, seizures, GI distress, yawning, sneezing
(if Finnegan score above 8 then send to children’s)
Care Management
Nursing care
Assessment
-Education
-Social support
-Pharmacologic treatment
-Drug dependence
-Breastfeeding (controversial)
Foster care, family placement
Finnegan ScoringKey Points
Small percentage of significant birth injuries may occur despite skilled and competent obstetric care
Key Points
Same birth injury may be caused in several ways
Key Points
Nurse’s primary contribution to welfare of neonate begins with early observation, accurate recording, and prompt reporting of abnormal signs
Key Points
Metabolic abnormalities of diabetes mellitus in pregnancy adversely affect embryonic and fetal development
Key Points
Prepregnancy planning and good diabetic control, coupled with strict diabetic control during pregnancy, may prevent embryonic, fetal, and neonatal conditions associated with pregnancies complicated by diabetes mellitus
Key Points
Infection in neonate may be acquired: In utero During birth During resuscitation From within the nursery
Key Points
Most common maternal infections during early pregnancy that are associated with various congenital malformations are caused by viruses
Key Points
HIV transmission from mother to infant
Transplacentally at various gestational ages
Perinatally by maternal blood and secretions
Breast milk
Key Points
Nurse often is first to observe signs of newborn drug withdrawal
Key Points
Providing high-quality perinatal care to a varied population with multiple conditions is complicated by special needs of high risk, drug-dependent clients
Key Points
Signs and symptoms of infant withdrawal vary in time of onset depending on type and dose of drug involved
Key Points
Rehabilitative measures must be included in the plan for care for the infant and parents to offer infant an opportunity for optimal development after discharge
